Incomplete Spinal Cord Injury (SCI)
What is it?
Mechanism of Injury (MOI)
Traumatic – mainly caused by MVA (Motor Vehicle Accident), and other high-impact injuries, especially in younger, male populations. Low-impact injuries, such as falls in the elderly, can also lead to a traumatic SCI.
Non-Traumatic – can occur secondary to inflammation, cancer, infections, or degenerative spinal conditions.
Presentation of C2 (Complete) SCI
- Leading MOI: Trauma (both high and low impact)
- Pathophysiology:
o Dens # → flexion/extension
o Pars (Hangman #)→ hyperextension, axial loading - Management: Surgical, external fixation (eg. halo, hard collar), conservative
- Complications: Non-union, malunion, pseudarthrosis formation, risk of airway compromise for anterior surgical approach
- Prognosis: Better for isolated, non-displaced fractures, and more favourable for early intervention
- Usually require ventilatory support, dependent on others for self-care
- Use power wheelchair for mobility, may require chin-control
- Use head, mouth or voice activated technology for independence
Overall Management of SCI
Acute Management of SCI
Goals: Stabilise the patient’s neurological and haemodynamic state, reduce risk of secondary complications as much as possible
- Conduct CT scans and other appropriate radiography
- Treat and manage autonomic dysreflexia
- Daily chest physiotherapy, ventilatory support and mechanical ventilation
- Surgery (eg. decompression, stabilisation, fracture reduction, deformity correction), bracing/halo/collar if required
- Bladder and bowel management, DVT prevention management (medical and non-medical)
- Early physiotherapy (ie. D1 post-injury) recommended; target >20 min of maximum tolerated aerobic activity per day
Motor and Non-motor Impairments
Decreased joint ROM, strength, CV fitness
Impaired motor skill and decreased coordination
Spasticity
Joint contracture
Cardiovascular dysfunction (eg. postural hypertension, elevated ICP)
Respiratory function
Postural hypertension
Pain, altered sensation
Pressure injuries/sores
Bowel/bladder dysfunction
Psychological/Emotional Distress
Non-Motor Complications after SCI
Pressure Sores
- Cervical SCI patients are far more likely to develop pressure sores and further health complications secondary to pressure sores
- Due to significantly decreased innovation to nearly all muscle groups, cervical SCI patients are unable to physically shift themselves out of uncomfortable positions. They are also likely unable to feel if their bony prominences are being pressed against a hard surface for a prolonged period, due to impaired sensory feedback from the neck down.
Respiratory Dysfunction - Higher risk of respiratory complications in cervical SCI patients due to decreased mobility, respiratory muscle fatigue, associated injuries such as a pneumothorax or fractured ribs…etc.
- Most C2 SCI’s require mechanical ventilation support as nearly all respiratory muscles are innervated from C3 onwards:
o Diaphragm → C3-5 via phrenic nerve
o Scalenes → C3-5
o Pectoralis → C5-T1
o Intercostals → T1-T11
o Abdominals → T6-12
Autonomic Dysreflexia – MEDICAL EMERGENC
- What it is: A potentially life-threatening syndrome involving an abnormal overreaction of your autonomic nervous system to a painful stimulus.
- Main signs and symptoms to watch out for:
o Sudden, severe spike in blood pressure
o Severe headache and sweating
o Bradycardia (ie. Slower than normal HR) - Mostly involves patients who have a T6 or higher level of SCI
Bladder and bowel dysfunction
- Bladder and bowels are innervated from S2-4 and receive important sympathetic input from T8-12
- Cervical SCI patients often require use of a catheter and are unable to properly feel whether they’re full, need to go, and unable to control when they are able to relieve themselves
Deep Vein Thrombosis (DVT)
- What it is: blood clot that develops in the deep veins within the venous system.
- If it travels up towards the lungs, the clot could get stuck in one of the blood vessels of the lungs and cause a cardiac/respiratory arrest.
Psychological and Emotional Distress
- Up to 40% of people who suffer a traumatic SCI are likely to develop PTSD, while up to 30% are at risk of experiencing depression
- Sustaining an SCI significantly affects quality of life and well-being, and can be difficult to adjust to the change in way of life, especially for traumatic SCI patients
Multidisciplinary Team Involved in Care and Their Roles
Surgeon (Spine/Neuro/Ortho) – conduct appropriate surgeries if needed, provide post-op precautions, apply spinal braces/collars/halo if needed
Nurse – manage continence problems, CV complications risk management, address and monitor day to day needs, check vitals, monitor ICP if needed
OT – assess impact of SCI on ADL’s, return to work, leisure activities…etc.
Physiotherapist
• Acute care: assess activity limitations, physical impairments, mobility, and transfers, provide chest physio, set goals related to bed mobility, gait, transfers, wheelchair mobility…etc.
• Long-term care: maintenance of physical condition, general well-being, extensive rehab individualised to the client’s impairments and their goals
Clinical Psychologist – assess cognitive, perceptual, and emotional/behavioural issues
Speech Therapist – assess swallowing, motor speech, voice, and communication
Social Worker – promote participation, community reintegration and assist with arranging social/financial support if needed
Nutritionist – design dietary plans that are updated in acute, subacute, and chronic recovery periods
References
AlphaBetaAustralia (2020) Spinal Cord Injury in Australia
eLearnSCI :(n.d.). Www.elearnsci.org. Retrieved August 30, 2023, from https://www.elearnsci.org/module.aspx?id=47&category=Physiotherapists&module=Setting+goals&lesson=Overview
Du Plessis, M., McGaffin, C. R., Molepo, T., Oelofse, R., Van Zyl, S., & Mashola, M. K. (2018). Perceived readiness for hospital discharge: Patients with spinal cord injury versus physiotherapists. The South African journal of physiotherapy, 74(1), 437. https://doi.org/10.4102/sajp.v74i1.437
leigh@happymonday.co.nz. (2023, February 21). Clinician Search Results | SCI Physiotherapy Clinical Practice Guidelines. Sciptguide.com. https://sciptguide.com/clinicians/clinicians-search-results/
Menger RP, Viswanathan VK, Notarianni C. C2 Fractures. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482287/
Ropper AE, Neal MT, Theodore N Acute management of traumatic cervical spinal cord injury Practical Neurology 2015;15:266-272.
Sandean D. (2020). Management of acute spinal cord injury: A summary of the evidence pertaining to the acute management, operative and non-operative management. World journal of orthopedics, 11(12), 573–583. https://doi.org/10.5312/wjo.v11.i12.573
Sasser SM, Varghese M, Joshipura M, Kellermann A. Preventing death and disability through the timely provision of prehospital trauma care. Bull World Health Organ 2006; 84: 507.
SpinalCord.com. (n.d.). Secondary Complications After SCI | Spinal Cord Injury | SpinalCord.com. Www.spinalcord.com. https://www.spinalcord.com/secondary-complications-after-sci-spinal-cord-injury#:~:text=After%20a%20spinal%20cord%20injury%2C%20one%20of%20the%20major%20secondary
SpinalCord.com. (2019). Spinal Cord, Inc. Spinalcord.com. https://www.spinalcord.com/pressure-sores-after-sci
Spinal Cord Injury Discharge Information Packet. State of Hawaii, Department of Health. https://health.hawaii.gov/nt/files/2017/11/S101817NTS_GuideForFamilyAndFriends-cmp.pdf
